Basic Information
| Provider Information | |||||||||
| NPI: | 1386128809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAFFER | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 9184594550 | ||||||||
| Practice Location | |||||||||
| Address1: | 16538 N MAY AVE | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730129007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-31756 | OK | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.